Direct, Transapical, Beating Heart, Off-pump Mitral Leaflet Modification to Facilitate Transcatheter Mitral Valve Replacement: Initial Experience in Three Patients

Background: Transapical mitral valve replacement (TMVR) has emerged as a promising alternative for treating severe mitral regurgitation (MR), particularly in patients deemed ineligible for conventional surgery or transcatheter edge-to-edge repair. However, anatomical challenges such as neo-left ventricular outflow tract (neoLVOT) obstruction, a hypermobile anterior mitral leaflet, or previous leaflet procedures such as an Alfieri stitch can pose significant obstacles to the implantation of a TMVR system. Although transcatheter electrocautery procedures have been developed, they are complex and time-consuming. Here, we present our experience with direct, transapical, beating-heart, off-pump mitral leaflet modification to facilitate transcatheter mitral valve implantation.

Methods: Over the past year, eight patients have received TMVR in our hospital. Direct, scissor-mediated, beating-heart leaflet modification was performed to prevent neoLVOT obstruction and systolic anterior motion (SAM) (n = 2) or to remove a previously performed Alfieri stitch (n = 1), restoring the single orifice of the mitral valve. To perform the procedure, standard apical access to the left atrium was first obtained, ensuring there was no entanglement with the chordae. An introducer sheath (26-F, 30 cm) was then advanced into the left atrium, with a wire kept in place within the atrium. Endoscopic scissors (43 cm, 5 mm) were introduced through the sheath into the left atrium. The sheath and scissors were retracted into the left ventricle, just below the mitral valve, and the sheath was further withdrawn until it was positioned just below the pivot points of the scissors. Under transesophageal echocardiography and fluoroscopy guidance, the edge-to-edge stitch was transected directly (n = 1) and the AML (A2) was incised from the free edge to the annulus (n = 2). The procedure was then completed with the implantation of the mitral valve (TMVR).

Results: The duration of the procedures ranged from 110 to 126 minutes, with no intraprocedural complications. All patients survived and were discharged from the hospital.

Conclusion: Direct, transapical, beating-heart, off-pump mitral leaflet modification to facilitate transcatheter mitral valve implantation is a viable and safe alternative for high-risk patients. This approach effectively reduces procedural time and enables leaflet modification to facilitate transcatheter mitral valve implantation.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
11 February 2025